Ep. 32 - Airway Fundamentals for Austere Settings

Prehospital Airway Fundamentals for BLS: Positioning, Pocket Mask, NPA/OPA, BVM, and LMA

Dr. Patrick Fink presents a BLS-focused airway fundamentals episode for prehospital and wilderness/SAR responders, emphasizing an ingrained, stepwise approach to stave off respiratory badness. 

Links:

Airway Fundamentals Video

Intersurgical iGel LMA

Chapters:
00:00 Airway Basics Overview
01:52 Questions And Upcoming Episodes
04:04 Scenario Mountain Biker
05:33 Airway Positioning Jaw Thrust
09:42 Pocket Mask Ventilations
13:24 Nasal Airway NPA
17:53 Oral Airway OPA
22:22 Putting It All Together
24:26 Oxygen And Bag Valve Mask
29:03 PEEP Valve Tips
30:29 Laryngeal Mask Airway
35:52 Full Airway Algorithm Walkthrough
38:39 What I Carry In My Kit
39:39 Practice And Mental Rehearsal
42:17 Wrap Up And Support The Show

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Transcript

Patrick Fink 0:17

Hello and welcome back to Wilderness Medicine Updates. I'm your host, Dr. Patrick Fink. Today I'm talking about airway fundamentals, the tools and tactics that you need to manage airway in the pre-hospital environment as a basic life support provider. So this means that we're not gonna be talking about intubation, cricothyroid, otomy. I am gonna talk about pocket masks, nasal and oral airways. A bag valve mask, and even laryngeal mask airways, because those may or may not be within your protocols. The goal here is to really dive into what I think is the core content for saving people's lives from respiratory complications in the pre-hospital environment. There's only so many things that we can do that actually help to save someone's life that can address an emergency. In the moment and fix a problem that would've otherwise killed a patient before they could reach the hospital. That's critical Bleeding. It's hypoglycemia, it's insufficient respirations, hypoxia, hypercapnea. It's good, high quality CPR in the right setting. These are the basic things that we really need to have totally dialed to have an algorithm ingrained in our brainstem so that when the brown stuff hits the whirly thing, you're not having to think through, okay, what do I do next and how do I do it? It needs to just be there as the foundation, and then you can build on that from there. Before we jump in, I just wanna say thank you to everyone who's been reaching out with questions. They're actually accumulating faster than I can address them, and some of them are pretty tough to find the right person. I've had a couple folks approach me with questions about, you know, if I'm a wilderness first responder, how do I know. What I can actually do, I'm not an EMS provider. What can I do in the context of a search and rescue team versus on my own? If I'm a medical director and I have these people on my staff, what can I let them do? So these are complicated questions, and finding the right person to answer them has been proving challenging, and I, I'm committed to getting these done. Other questions. I've had very specific questions about, uh, specific therapies and frostbite and those are gonna get wrapped into when I do full episodes on those things. Also, in the background, I'm working on bringing you some episodes, more cases, real cases from out in the world of search and rescue and, austere medicine so that you can just. Get more experience on, on interesting cases from interesting people. So those are all exciting things that are to come and as we wrap up this weird North American winter and look towards summer, we're gonna pivot the mind towards heat illnesses, maybe some inves, and focus on, uh, potentially also some traumatic injuries so that there's a lot of good things to look forward to. If you're just encountering this podcast for the first time, make sure that you subscribe so that that content comes straight to you, and someday maybe I will become more adept at social media or willing to participate, and you'll be able to tune in and get updates that way as well. Finally, I have a video to go along with this podcast that shows you the tools, shows you the techniques. So look for that in the show notes and be sure to take a look at that. It's about 15 minutes long. Definitely worth looking at. And then circling back, you know, for a refresher once, once every now and again, worth taking a look at and then approaching for a refresher occasionally if you feel like you need to brush up. I hope it's useful to you. Now let's dive in. Let's imagine that you're either a lay responder or you're part of a search and rescue team in the middle of a response and you encounter a mountain biker. It was adjacent to the trail. They've clearly fallen. They're next to a tree. They're in an uncomfortable looking position, and they're staying there and they're not doing anything about it. It is clear that this person is injured. You are encountering them with just what you are carrying on your person. A basic medical response kit that you carry as part of search and rescue or perhaps, part of your daily carry kit. And you need to respond to this person. So you approach, you yell, you see if you can get their attention and they're just not responding to you. So you carefully roll them over onto flat, onto their back, maintaining spinal precautions as as able, um, but really, you know, a B, CS start with a, so we need to be able to access the airway. We roll 'em over and. They're sort of trying to breathe. They've got snoring, respirations. You can tell that this person is not breathing appropriately. You are gonna be at this patient's side for the next 20 odd minutes managing this patient until you get additional help. Do you have the tools and tactics and a plan for how you're gonna do that? If you don't, I'm gonna give it to you now. Airway positioning. So if you take a basic life support course, you're gonna get taught two ways to open a patient's airway. This mountain biker in front of us is snoring. That means one of a few different possibilities. Maybe they simply need the tongue moved outta the way. Or maybe they're at a depressed level of consciousness and the tone, the muscular tone in the back of their airway is quite poor, and so they're sort of just snoring on all of their soft tissues back there. Well, the first thing we need to do in someone who is trying to breathe but not breathing enough is just open the airway, create a clear passageway for air to move. And the two ways that you get taught to do this are a jaw thrust and a head tilt. Chin lift. The head tilt, chin lift is the moving the patient's head into what is commonly referred to as a sniffing position. Basically, head extension chin up towards the ceiling, and that's the preferred thing for bystander. CPR. For a HA. However, in. Essentially any trauma patient, this is not the tactic we want to use because we're putting the spine into a position of extension. We're potentially manipulating an injured spine in an, in a way that could cause secondary injury. So instead my rote go-to first approach to any patient who does not have an open airway. Is the jaw thrust. And the jaw thrust is placing your thumbs right below the patient's eye sockets on the bony prominences of the face, and then hooking the rest of your fingers behind the angle of the jaw, pushing down with the thumbs, pulling up with the fingers, and thrusting the jaw up towards the sky. When we perform that jaw thrust, what we're doing is two things. The first is that we are pulling the jaw up off the back of the oropharynx, the oral cavity, and with it we're pulling the enemy of the airway, the tongue up off of the back of the hard palate and the oropharynx, and we're creating space. We're creating space back there. The second thing that we're doing is that this is an incredibly obnoxious thing to do to somebody. Try it on a friend, they're not gonna let you get very far. So in someone with a slightly depressed level of consciousness. Or a significantly depressed level of consciousness. This can be enough painful stimulus to kind of wake them up enough that some of their airway tone comes back. They kind of come round just enough that you get better respirations, better tone, easier air movement. It's uncommon, or quite uncommon to. See this really wake someone up who is truly snoring. If they were, they're probably more asleep. Or maybe this is someone with opiate overdose, something where they're kind of in and out of a reasonable level of consciousness in a trauma patient, I've never seen this, wake them from the dead, but between the held tilt chin lift and the jaw thrust, you wanna do the jaw thrust as your initial tool, and then you want to reevaluate how things are going. When I was in medical school, there was a intersection near our apartment that was very bad for connecting cars with bicyclists, and I responded to multiple accidents out there. And one of these accidents, there was an unconscious cyclist, was snoring, respirations, and all I had to do was get down. Next to the head and perform a jaw thrust. And with that went from snoring respirations to good respirations. Vital signs look good. And I basically sat there holding a jaw thrust until more help arrived. And that was the only airway intervention that was initially needed for that patient in that moment, and they were able to transport that way as well. So it's a very useful tool. However, once you perform that jaw thrust, if the patient, you know, the air is now moving in and out nicely, but they're just not breathing enough because they're, they have a depressed level of consciousness. You see a respiratory rate of four or very shallow panting respirations, and it's clear that this patient needs more air to move in and out. We now need to move to our next tool in our armamentarium, the pocket mask. The pocket mask is the tiny little tool that is stuffed in every little a ED box, and which should be in every first responder's pocket somewhere, because if you need to breathe for somebody and you're by yourself, the pocket mask is by far the easiest, quickest first line defense to put something between you and the patient and let you give them some breaths. Now a pocket mask is just a little plastic cup with a rim around it and a nice little hole in the middle with a valve so you can place it over the patient's face and blow air into their lungs. Simple, right? No, unfortunately it's a little bit of a tricky skill. So the first thing I want to tell you about pocket masks is make sure to expand the mask. I've seen this in some first responders. The mask comes kind of flattened into itself. It needs to be expanded, like one of those like pop-up dog bowls. Make sure to expand the mask, and then the narrow portion of the mask goes towards the nose, the wider portion down towards the chin. You need a one-way valve on your pocket mask. Go check out your mask and make sure you have this, it looks like a big white disc. You should not have a clear hole through your pocket mask. That's to protect you. And that's because the kind of people that you're gonna perform these respirations on are the kind of people who end up with overinflated stomachs and who are going to try to vomit in your mouth. And you don't want the vomit in your mouth. So if you don't have a mask with a one-way valve on it, go get one pause. Pause the video, go to Amazon, go to North American Rescue. Get a pocket mask with a valve on it. Now, the key technique for using a pocket mask is that just like a jaw thrust, we need to pull the patient's face up into the mask. Don't push the mask down onto the patient. Because we need that tongue, that all that tissue up off the back of the mouth if you smush that mask down on the patient's face. 'cause you really wanna make a good seal and make sure the air gets in there. You're just smushing all that tissue in there and the space that you want to try to pass air through is now just, is like trying to blow through lasagna. It's not gonna work. So pull the patients. Face up into the mask using a grip that is just like that jaw thrust. Two hands on each side of the patient's face. Thumbs on top of the mask, fingers behind the jaw. Pull the jaw up into the mask. You can then give breaths through the mask. You know, give one breath every six seconds. A reasonable volume, just like what you would be doing if you were breathing. You breathe in. Breathe out into the patient. Fantastic. Last thing of note on the pocket mask is that for some reason, in my experience, the diameter of the valve that's on there is not the same as the diameter of a bag valve mask, which means that if your friend shows up with a bag valve mask, you can't simply stick the bag on the mask you're already using. You're gonna have to contaminate another one. Why? I don't know, sells more pocket masks, but just be aware of this. You can't readily use it when someone else shows up with another tool. It's probably not gonna hook up to this thing. So now you're stuck. You're holding the patient's face up into the mask. You're giving these respirations. What if you're not getting air in and out terribly well, or it's just too much work. You're having to perform a really aggressive jaw thrust. This is just really hard work. Or you feel like you're not getting enough air into the lungs with each breath it's, it feels like there's a lot of resistance. You know, you're, the air you're blowing in is coming out around the masks. It's making the patient's cheeks shutter instead of causing chest rise and you feel like you're not getting good respirations, then you need to move on to our second tool. The nasal airway. The nasal airway or the nasopharyngeal airway is an airway adjunct designed to make ventilations easier. It's useful in both unresponsive as well as less responsive patients, and it's basically a nice silicone straw with a flange on it that you can stick down through the nose and create a clear passageway into the or of pharynx. They come in a variety of sizes and you know, there's a textbook way to size these, which is if, if you ever have to take a test, the answer for how to size this is to go from the rum of the nose, which is the middle of the nose, where a bowl would have its ring to the trauss of the ear. That's the little firm cartilage right in front of your ear canal opening, where sometimes people get a little piercing. So if it goes from the middle of the nose to the. Traga Tragus of the ear. That's supposedly the right size. However, the problem is that there's a lot of variability, manufacture to manufacture in terms of diameter versus length on the nasal airway. So my practical approach is this. You carry a variety of sizes from smaller to larger. You look at the patient's face. Look in one nostril, look in the other. Does one nostril look bigger? Does one nostril have a nasal septum that's blocking it? Whichever nostril looks bigger, we're gonna use that one. And we're gonna approximate what we think is the largest nasal airway that we have that will go into that hole, lubricate that airway, and try to slide that thing in. When you insert a nasal airway, we're not putting it up back towards the brain. We're not going back up along the top of the bridge of the nose. Think of it as going along the floor of the nose. Parallel to the palette towards the back, level with the ear lobes almost traveling along the floor of the nose and just hub it. Go all the way up to the flange. If you're giving respirations through this thing and you feel like there's a lot of resistance, try backing it out. Because the issue is that if it's too long, it can actually go too deep and and potentially be trying to ventilate the esophagus or tickling the vocal cord so it can run up into tissue, back it out a little bit. But generally speaking, the biggest nasal airway that you can put in is the best nasal airway. And if you wanna put two in one on each side. Go for it. You can double barrel it. This has the same advantage as the jaw thrust in that it both creates a patent airway and it is obnoxious. So someone who is slightly subconscious, uh, may receive some arousal, some stimulus from this, and can improve their own airway tone. For you, and sometimes this may be all you need. If they're breathing enough, you know they have some sonorous respirations, you can sometimes just throw in a nasal airway. Great. Now they're breathing through that thing, but they're breathing enough on their own. You need to be watching your pulse ox if that's all you're doing, but that's, that's a great initial tactic. A few notes of caution. One, if you encounter resistance putting in a nasal airway, chill out. Don't try to push through the resistance. This takes a little bit of experience to know how much is too much force, but I would say don't use more force than you can comfortably, push on the end of your own nose with, if it hurts enough. When you push your nose with that amount of force, you're pushing too hard, you're encountering some kind of resistance. Second, don't use a nasal airway if there's significant nasal trauma or trauma to the roof of the mouth. Or if you suspect that the patient has a skull fracture like they've, they're post-trauma and they have black eyes, unstable facial bones, bruising behind the ears, bleeding from the ears. Why? Because it's poor form to put a nasal airway into someone's brain if you run straight back to the back of the nasal passages. You encounter the cribriform plate, which is a porous portion of the skull where nerves pass through, um, from the brain into the, the nasal cavity. And that is an area that if fractured is now a potential pathway for that nasal airway, not to go into the airway, but up into the brain and that there are a few case reports of that, and you really don't want to be that guy. So if there's significant trauma to the, uh, nasal airway. To the upper face, or if there's evidence of a skull fracture, that's not the patient to be shoving a nasal airway into. Now what if you need more help? What if the nasal airway isn't doing it? That's when I move on to the oral airway. The oral airway or OPA is. An adjunct to assist with ventilation. But unlike the NPA, this is useful only in patients who are unresponsive and who don't have a gag. So they're pretty out of it. It's essentially sort of a curved plastic, spoon like device or I, I think of it as if I had two gloved fingers and I reached into the back of that patient's mouth and I pulled their tongue forward. It is doing that motion for me. That works for opening a patient's airway. Then you're just stuck with your hand in the patient's mouth. So instead we use the oral airway, these curved plastic devices, again with a flange so the patient doesn't swallow it. We throw these things in if the patient fights the placement, so they're like, or they gag that patient cannot tolerate an oral airway and you need to take it out because triggering a gag can cause vomiting, which in turn can cause aspiration. So the oral airway helps us in three specific ways. First, it pulls the tongue off the back of the mouth, like I was just saying, you know, it's like two fingers in the back of the mouth pulling that tongue forward. Second, it provides a direct straw like channel to the back of the mouth. They're usually hollow, so if nothing else, you get that passage through the device itself. And then third, it acts as a bite block that keeps the patient from clenching their mouth closed, which can sometimes happen in significant head injuries. This is another case of how do you size it? There's a test question, answer, and then there's a real world answer. The test question answer is that you measure from the ear lobe to the corner of the mouth. The real answer is that most adults take the same size oral airway, which in my experience is usually the one that is red plastic color. If you need to carry just a few of these, it's better to have an oral airway that's too big than one that is too small. But for some reason the one that fits most adults is, is usually red. Okay. To insert the oral airway again, there is a textbook answer and then there are real world answers. The textbook insertion for reasons which is aren't unknown to me, is they tell you to put in an upside down with the, the tip of the thing curving towards the roof of the patient's mouth. And I think that the idea here is that you don't want to take the airway. The oral airway and shove the patient's tongue back into their mouth as you're trying to insert it, that's counterproductive. So they think, okay, if you put it in kind of upside down as far as you can and then you flip it over, it's a way to sneak back behind the tongue. Personally, my preferred tactic is to use a gloved hand to open the mouth and I actually hook downwards on the tongue with a finger like I was talking about, like, like playing the role of the airway myself, creating a space, and I slide the airway, you know, curving along the surface of the tongue, back into the back of the oropharynx. That said, you know, if, if you have to, you can always turn it sideways to place it. You can come in from the side. There is no wrong way, so long as you're not shoving the patient's tongue into the back of their mouth as they do it. If someone has a particularly large tongue, say anaphylaxis or a down syndrome, you can sometimes use a piece of dry gauze, like a four by four gauze to grip the tongue. With one hand, pull it forward and out of the mouth to create space and insert the oral airway behind it. Just as a reminder, our contraindications here for this device. Don't use the oral airway if the patient is gagging or alert or doesn't tolerate it. And then just like the nasal airway, if there is significant trauma to the mouth, you don't want to place. That oral airway in the midst of unstable bones, you don't want to be causing more trauma in a space that isn't well-defined anymore that you know potentially doesn't confine the oral airway to the usual position. I think that this should be readily apparent, but could be forgotten in the moment. You don't wanna put an oral airway into anyone who has foreign body in the back of the throat or in the back of the mouth. So when you're opening the airway, just take a look. You know, if, if it's a kid with a foreign body aspiration, there's a plastic bag back there. We don't wanna be sticking the airway into that and shoving it deeper, shoving it down into the vocal cords. We need to clear any obstruction first. So let's return to the mountain biker. You have the mountain biker in front of you. With the snoring respirations, you perform the jaw thrust that improves the sonars quality of the respirations, but there's not enough air going in and out. So you reach for your pocket mask, you expand it, you place it onto the patient's face, and you pull the patient's face up into the mask so that you're getting a good seal. And you start giving breaths that's working somewhat okay, but you feel like the air isn't going in and out quite how you want it to. So you back off for a second. You open your nasal airways quickly evaluate for nasal trauma. There's no evidence of facial bone fractures. There's no bruising around the eyes or at the base of the skull. So you lubricate a nasal airway, fire it in one side, lubricate a nasal airway, fire it in the other side. Give a couple breaths. Great. It's improved a bit, but I want a little bit more. So again, you back off, open the patient's mouth. Slide in an oral airway following the curve of the tongue. You used the red plastic one because you know it fits most adults and, and you checked it on, you know, ear to the corner of the mouth. Looked good, patient tolerates it well, no gagging, no foreign bodies in the back of the mouth. You've now double barreled the nose and you have an oral airway in the mouth. And when you're performing respirations with your pocket mask, you now have good air movement and also the airway is being held in a good position so that when you need to take a break, do something else and come back to your respirations. Now you're not having to spend a bunch of time repositioning, You're just pulling the patient's face up into the mask, and it's already in a great position to de deliver breaths. This is a situation that you can continue for some time, but it's also very inconvenient and uncomfortable. The patient's on the ground, you're having to stoop down there and blow into this hole. You're not gonna accomplish much else, but thankfully, you know, you had that presence of mind to call for help or be part of an organized response. And so after a period of time, additional rescuers arrive on the scene. How do we add to this patient's pre-hospital airway management using just basic tools? The first thing that any organized rescue is gonna bring to this party is oxygen and a bag valve mask oxygen is great. We can add it in any context. Most pocket masks don't connect to an oxygen tank. That's fine. They will connect to a bag valve mask. You can always put a nasal cannula on the patient and then put a mask over it if you need to get some oxygen into the system and you don't have a bag valve mask, oxygen in the short term is not gonna hurt most patients. So anyone who's unresponsive, whether it's a trauma patient, a medical patient, anyone with insufficient respirations, put on the oxygen, and then you can always wean it down later once you have more information. But that brings us to the bag valve mask of all the tools discussed today. The bag valve mask or BVM is the single hardest one to use, and the reason that it's the single hardest one to use is that it is at least a three handed tool. What do I mean by that? I mean that getting a good mask seal with a bag, valve mask requires two hands. I don't care how cool you think you are. Your one handed CE grip is insufficient in most settings. Sure. If you're a single rescuer, you can try it. But really once the bag valve mask arrives on scene, you've got at least two people. One of those people needs to be sealing the mask against the face, and then the other one can be the third hand who squeezes the bag? In a lot of EMT or rescue courses, you're gonna get taught this CE grip, the one handed CE grip, and the CE grip is thumb and second finger are on top of the mask. And then the other three fingers are trying to do this awkward jaw thrust thing, and that hand is sort of smushing and raising the patient's face. This was developed in the operating room for anesthesiologists who are inducing anesthesia. In a perfectly positioned patient who's perfectly preoxygenated, and they need to be able to provide a few breaths with their anesthesia machine while putting the patient off to sleep. It was not designed for prolonged ventilations in the pre-hospital environment of an imperfectly positioned patient who has unstable physiology and needs high quality respirations for quite some period of time. You just can't do a good job with the one handed grip. So unless you are for some reason a solo rescuer, you need to do a two handed grip. And that two handed grip looks exactly like what we were doing with the pocket mask from the top of the head. The bottom of the head, it doesn't matter. It's thumbs are on top of the mask, and the rest of the fingers are gripping behind the angle of the jaw. And just like the pocket mask, we're not smooshing it down into the patient's face, we're pulling their face up into the mask to create that seal. That's the gold that I have for you about the bag valve mask. Once you have a good seal, you can provide good ventilations by simply squeezing the bag, using the same adjuncts that we've been using up to that point. You can slap the thing right on over your NPAs, your oass, and provide respirations in a two rescuer team. When you're setting it up, hook up oxygen tubing to it and throw it on 15 liters a minute if you have enough or just a couple liters if you feel like you're gonna be out in the field for quite a long time. And then one person provides the seal, the other bags. The one who's squeezing the bag needs to check their own sympathetic tone, breathe, slow down their own breathing, relax and provide respirations and a calm, slow, and steady manner. You're gonna squeeze the bag gently. You're not flattening it. You basically just wanna squeeze until you see a little bit of chest rise. It's usually like half the volume of the bag. And again, we're gonna do this every, six seconds or so, so that you're getting a respiratory rate of 10. I'll remind you here that the mask itself doesn't fit onto a pocket mask. They use different diameters for no good reason. However, if you are using something like a, uh, laryngeal mask, airway, or an endotracheal tube. The bag valve mask does fit perfectly onto those fittings. They thought that one through. So u usually the bag valve mask comes with its own mask. Use that one with the bag. It's the one that fits. Hook the oxygen up to that one and use that one. One small adjunct that can be useful for the bag valve mask. Some of them come with a little. Pressure manometer on there. That tells you if you're squeezing it too hard. Uh, those aren't super useful. But a little cheap addition to your bag valve mass kits is to add what's called a peep valve. PEEP is positive end expiratory pressure. And this basically says when the patient tries to breathe out, we're gonna let them breathe out against some resistance. This kind of stents open the airways. The scope of discussing PEEP is beyond this podcast. It's kind of more of an advanced airway topic that we could be talking about ventilators, but a peep valve put on your mask. Instead of the little exhalation port, you just pop off the useless little plastic piece where the air comes out and you stick this little thing on. You can screw it to set it to five, 10, or 15 millimeters of mercury. Five to 10 is a great number. This helps you bag people who are harder to bag. So if their CPR in progress or the patient is obese, you're having to work against some resistance. A little peep can be super helpful in those patients. And a peep valve is super cheap and basically never expires, so you can just fit them under your bag. Valve masks. You know, in the sarc, so they're ready to go out into the field. Super helpful, super useful, super cheap. Definitely look into them. Finally, let's talk about laryngeal mask airways. Briefly, I said that this was a BLS directed podcast. I'm stretching it a little bit here by talking about laryngeal mask airways. It's gonna depend on your protocols, depend on your state, depend on your certifications, depend on your medical director what you can and can't do with these things. They are considered an advanced airway in most settings. However, they're also super simple to place and they can be extremely helpful. Let's talk about this as the end point of our pre-hospital airway algorithm, and then at, at some point in the future, we can talk about fancy dance stuff like intubating patients in the field, RSI, you know, cricothyroid, otomy. Those are fringe cases. A lot of times your airway algorithm can march you up to an LMAA laryngeal mask airway, and it can stop there for quite a long period of time in a lot of patients. So what is an LMA? An LMA is an advanced airway tool that is used to deliver your ventilations more directly to the trachea, and it tries to block the esophagus or any secretions from going into the trachea. It's basically a soft, you know, micro mask that's in the shape of a cupped hand. With a tube coming off it that slides into the back of the throat and cups straight over the vocal cords delivering whatever you shoot down that tube, straight into the cords and blocking off the esophagus. Take a look at the video in the show notes or just Google IGEL I-G-E-L-L-M-A and you'll find the inner surgical IGEL with some nice pictures of how it interacts with the airway. They're great because you don't have to paralyze a patient. You can slide it into an unresponsive patient like you can. A oral airway, but because they're delivering respirations directly to the vocal cords, you're not going to have to deal with obstruction from the tongue or the oropharynx. You're not going to be inflating the stomach as much, which can then cause vomiting or aspiration. So the laryngeal mask airway is fantastic, and there's a variety of brands out there from super basic to super fancy. I am a big, I take no money from them. I have no affiliations, but I do really like the inter surgical IGEL airways because they don't require inflating. There's no moving parts. They're fairly idiot resistant, and I'm an idiot, so I need that. Like Oral Airways. The LMA is appropriate only for unresponsive patients who tolerate its placement without gagging. These people are out. There are a range of sizes in the IGEL, it runs from basically neonates to large adults. There's weight-based sizing on the little boxes that they come in. Um, in most humans, a green IGEL fits an adult. Orange is for Andre the giant and yellow is for a slightly smaller human, but, uh, you can keep a couple sizes handy in your kit depending on how far you have to walk. I keep a, um, IGEL size four in my vehicle as part of my, you know, kind of personal response kit because it's gonna fit the majority of situations. It is really simple. You just lubricate the thing, rest it back in its box, put a little strap behind the patient's head so it's ready to secure. And then when you want to put it into the patient, you're gonna jaw thrust them or hook the tongue like you would to place an oral airway and then insert inserted along the curve of the tongue and it seats firmly into the back of the throat kinda snugs down there. And you can tell that you're essentially. Hubbed into the anatomy. You secure it with an elastic strap and throw the bag valve mask onto the laryngeal mask airway, provide your ventilations through it, but a bing, but a boom. The upside of the LMA is that you now have a really secure device in the airway. It's not, it's strapped in. You know, it can take some jostling at any time. You can pause the bag, valve mask can kind of hang off of the thing, and then you can come back and provide respirations. It's there for you throughout your transport. There's no having to, you know, come back to the patient and perform a jaw thrust or reposition the airway before you can give a breath. And if the patient is having bleeding or vomiting, or it's a prolonged transport and you're worried about. Insufflating the stomach or other complications of prolonged bagging. They're great airways and they can sometimes take a little bit of troubleshooting. If you hear some air coming from around the IGEL, when you're ventilating, you can just gently reet the IGL into the back of the throat. It can sometimes start to ride up. If that doesn't work, you can consider moving to a larger size of airway. On the other hand, if you stick an LMA into a patient's throat and you're like, that thing is in there, I know it, but you can't ventilate through it. That usually means that it's too large. It's either not, it can't get down low enough, isn't seated well, or, um, the way that it's sitting, it's, it's actually occluding the airway with the kind of buffer around the cuff. So if you can't ventilate through it, it's probably too big and you want to downsize. So let's return again to our patients so we can ingrain this in our brainstem, and it becomes a pathway that we can march through without issues. It's not a, it's not a protocol. Every situation is different. You need to be able to modify things slightly. But this is how you can march through your tools in a patient with inadequate respirations and tune it to the patient as you need to. So we arrive on this patient who's minimally responsive. We check for pulse, we check for respirations. If respirations are inadequate, we're gonna check that there's no foreign bodies in the mouth. Do a strong jaw thrust and reevaluate. If their breathing is still inadequate, we're now gonna deploy our pocket mask. To assist with ventilations, we're gonna pull the patient's face up into the mask and gently push the mask down into the face, give a few breaths, and then improve our situation. If air is going in and out, great. But if it's not perfect, we're gonna take a pause and we're gonna place a nasal airway or an oral airway if the patient tolerates it, heck, if you have a mole in front of you and the patient is tolerating it, I'm gonna place two nasal airways and an oral airway because that takes me about 30 seconds tops. I'm then gonna resume ventilating using that pocket mask. Fantastic. I now am moving air in and out. I am giving respirations the patient's getting oxygen and the CO two's coming out when more resources arrive. Now I'm gonna switch to that bag valve mask over the NPA and OPA. I'm gonna use a two person technique because it's a three handed procedure, so I'm gonna use two hands to seal the mask, and my buddy is gonna squeeze the bag gently until they get chest rise. And then when our a LS colleagues arrive or if, uh, if we have the skills and approval to use it, if the patient remains unresponsive and I want something more secure, more durable for transport, something that's gonna make my life easier, I'm gonna remove the oral airway and place a laryngeal mask airway. I'm gonna secure it in place. I'll leave the nasal airways in place in case I need them in the future. And now I'm gonna ventilate through that LMA using the bag valve mask. If I was to arrive on this patient with a team of two rescuers and we had to march through this entire algorithm, I think you can get through this in under a minute because you're gonna just perform an intervention and evaluate the response. Or using your experience that you've accrued. Over time, you're gonna know that this patient is obtunded and is gonna need all the airway adjuncts that they can tolerate. And so you're gonna march right up your airway algorithm, essentially to the highest, most secure airway that you can hook up your oxygen and then start working on the other problems. Move on. You've moved from A to B and it's time to evaluate C, D, and E. So that's my pre-hospital airway plan for basic airway adjuncts. I carry all of these things on my person when I respond. I have a pocket mask. I have a small Ziploc bag of nasal airways. I have a small Ziploc bag of oral airways. Both of those Ziplocs have a little packet of surgical lubricant in them. I also carry an LMA and our medical kits have a whole range of sizes of these as well. They also have pocket BVMs. So I'm able to march through this airway algorithm up to, I have NPAs and Oass in place. I have my own pocket mask. I'm giving respirations, and I'm ready to transition when my friends arrive with more tools. I think in most front country applications, you can have even more tools. You can have a pocket BVM. If you're using vehicles, you can have a small oxygen tank, and that's gonna address the majority of your situations, particularly, or if you're able to place LMAs. So I hope that this is super useful to you. If it feels just so basic. If you're like, man, this is so boring. Can we just talk about needle ventilation? Just, you know, ventilating someone through a needle in their neck. That sounds cool. Think about what you are most likely to do that is going to save someone's life and think about how you can get a little bit better at those skills. I. Think about what you are most likely to do that's gonna save a patient's life. What procedure are you most likely to perform and are you excellent at those activities? Can you perform those interventions without having to think back and try to recall an algorithm? Are they deeply ingrained? Because if not. Listen to this podcast again in two weeks. Watch the video I made. Come back to it in a month. Visualize this downed mountain biker, the skier in a tree. Well, the climber who just had a ground fall at the base of the cliff and is altered. Imagine in thorough detail that you are the person who responds to that situation. Feel the sense of urgency and uhoh that is going to hit you. And then through that psychological cloud, know your way forward and visualize yourself performing the interventions that we just talked about so that when that thing happens, you're ready, you're ready to perform those interventions and they're gonna be in there like a reflex. And then as we move forward, we'll add to that. We'll talk about. You know, emergency cricothyroid, otomy, we can talk, we've already done a couple cases that involved intubation in an austere environment, but the, those exciting cases, they're somewhat fringe. You know, your, your basic airway management, that is the bread and butter, and that really is what separates your experienced. Field operators, SAR personnel, ski patrollers from the rookies is being really facile with these tools. So go play with your own med kit, get these tools. If you don't have them, watch the video. And if you haven't been trained on this stuff before, don't make this podcast your only training. I'm not your medical director. I'm here giving you good information to get you interested, but go out there, get hands-on training from people who can show you in person these techniques, and then go help people save some lives. That's it for this episode of Wilderness Medicine Updates. I'm your host, Patrick Fink. I appreciate the time you took to listen to this. I hope that you learned something that you were gonna take out into the field so that you can be a better medical provider and help those around you provide better care to your patients under stressful, challenging situations because what you guys do out in the field matters, and I wanna support you. If you found this podcast valuable, or you know someone who would benefit from doing this mental rehearsal, please share the podcast with them. Now, the two ways that can help grow this show are if you share this podcast with someone, or you take the moment right now to open up iTunes, open up your podcast app, just click on the show and give it a five star. Rating. You don't have to type anything, just rank it. Five stars, move us up in the algorithm so that when someone searches medical care or global health or wilderness medicine, this is the show that comes to the foreground and is recommended to them. And this show gets in front of more ears and out into the world where it can do some good. If you have questions, comments, concerns, feedback, think I've done something wrong, or just wanna say, Hey, my email is wilderness medicine updates@gmail.com. I read everything that comes through there and I do eventually get back to everyone, address all the questions. We will get there folks, we will get there. You guys asked some tough questions, but I do my best to bring some content to you. So that's the end of the show for today. Visualize yourself with that traumatic injury and visualize success until success is a reflex. Until next time, stay fit, stay focused, and have fun. I.